- Robert C Hyzy, MD
Robert C Hyzy, MD
- Professor of Medicine
- University of Michigan Medical Center
Extubation refers to removal of the endotracheal tube (ETT). It is the final step in liberating a patient from mechanical ventilation. Issues that need to be considered prior to extubation, the extubation procedure itself, and management after extubation are described here. Outcomes following extubation are also discussed. Predictors of weaning success and methods of weaning from mechanical ventilation are reviewed separately. (See "Weaning from mechanical ventilation: Readiness testing" and "Methods of weaning from mechanical ventilation".)
PRIOR TO EXTUBATION
At the end of the weaning process, it may be apparent that a patient no longer requires mechanical ventilation to maintain sufficient ventilation and oxygenation. However, extubation should not be ordered until it has been determined that the patient is able to protect the airway and the airway is patent.
Airway protection — Airway protection is the ability to guard against aspiration during spontaneous breathing. It requires sufficient cough strength and an adequate level of consciousness, each of which should be assessed prior to extubation. The amount of secretions should also be considered prior to extubation because airway protection is significantly more difficult when secretions are increased.
Extubation failure is highest when a combination of risk factors is present. As an example, when reduced cough peak expiratory flow rate (≤60 L/min), increased sputum volume (>2.5 mL/hour), and impaired neurologic function (inability to follow commands) are present, the incidence of extubation failure was 100 percent, compared to 3 percent when none of the risk factors were present (relative risk 23, 95% CI 3.2-167) .
Universally accepted threshold levels of cough strength, level of consciousness, and suctioning frequency that prohibit extubation have not been established. For many patients, it seems reasonable to delay extubation if the cough strength is weak, the Glasgow Coma Score (GCS) is <8, or suctioning is required more frequently than every two to three hours. However, the final decision to delay or proceed with extubation should be made on a case-by-case basis since delayed extubation is associated with adverse outcomes, such as ventilator-associated pneumonia and increased length of stay .
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